- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,905.46
| Professional | | $1,000.00 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,570.40
| Professional | | $2,041.74 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,862.09 / $6,606.93
| Professional | | $912.01 | $1,862.09 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,344.23
| Professional | | $1,905.46 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $537.03 / $537.03 / $630.96
| Professional | 26 | $537.03 | $537.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,137.96
| Professional | | $1,380.38 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $371.54 / $501.19 / $575.44
| Professional | 26 | $371.54 | $501.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $2,187.76
| Professional | | $1,174.90 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,344.23
| Professional | | $1,905.46 | $2,290.87 | $2,344.23 |